Modified constraint-induced therapy for children with hemiplegic cerebral palsy

Constraint-induced therapy is an intervention employed to improve upper limb function for people with hemiplegia. Traditionally, this intervention involves constraining the unaffected upper limb with a splint or cast, worn for most or all of the day, for 2 to 3 weeks. The premise underpinning this intervention is that constraint of the unaffected arm increases use of the affected arm and this, combined with structured adjunct therapy for 6 or more hours per day, improves the motor ability of the affected arm. Constraint-induced therapy was introduced for children with cerebral palsy following evidence that it could improve upper limb function for adults with hemiparetic stroke. Modified forms have subsequently been developed with the aim of being more clinically feasible and child and family friendly. The work undertaken as part of this thesis followed an evidence-based practice framework to explore the effects of a modified form of constraint-induced therapy. The guiding clinical question was whether modified constraint-induced therapy was more effective than a block of standard occupational therapy for improving ability to complete important activities of daily living and upper limb function for children with hemiplegic cerebral palsy. Research literature was systematically and extensively searched and appraised to find evidence to answer this questions (Chapter 2). Although some evidence existed that constraint-induced therapy improved upper limb function in children with cerebral palsy, there was insufficient evidence to justify adopting this intervention in clinical practice without further evaluation. The modified form of constraint-induced therapy developed as part of this body of work incorporated knowledge generated by consulting pertinent research with clinical expertise and the preferences of families of children with cerebral palsy (Chapter 3). The result was an intervention considered feasible for families and therapists to implement. This intervention involved use of a mitt worn on the unaffected hand for 2 hours per day for 8 weeks. During the time the mitt was worn the child engaged in fun, motivating, motor therapy. This therapy targeted upper limb movements considered fundamental to completion of activities of daily living identified by families as important outcomes of intervention. Modified constraint-induced therapy was then evaluated in two stages: a feasibility study (Chapter 5) and a randomised trial (Chapters 8 and 9). The purposes of the feasibility study were to i) determine whether the intervention was acceptable and practical to implement and ii) test study procedures in preparation for a randomised trial. Ten children (median age: 3y 6m) were assessed at baseline, at completion of intervention and at 6 months post-baseline. Modified constraint-induced therapy was considered acceptable and worthwhile by participants’ families. The study also facilitated the acquisition of knowledge regarding recruitment of participants, delivery of assessment and intervention, and utility of the outcome measures. The data informed sample size calculations conducted in preparation for the randomised trial. In the pragmatic, assessor-blinded trial, 50 children with hemiplegic cerebral palsy (mean age 49 months, range 19 months to 7 years 10 months) were randomised to one of two 8-week interventions: modified constraint-induced therapy or a block of standard occupational therapy. The primary outcome measure was the Canadian Occupational Performance Measure (COPM). Endpoints were at completion of therapy and 6 months. Between-group differences were neither clinically important nor statistically significant for any of the outcome measures at either endpoint. For example, the mean difference in COPM Performance (a 10-point scale) at completion of therapy was 0.3 (95%CI = -0.8 to 1.4; p = 0.61) and for COPM Satisfaction was 0.1 (95%CI = -1.1 to 1.2; p = 0.90). Three additional pieces of work were undertaken concurrently with the development and evaluation of modified constraint-induced therapy. An association between upper limb dysfunction and participation limitation of children with cerebral palsy was proposed (Chapter 4). Practical aspects of implementation of modified constraint-induced therapy were detailed in a chapter of an edited compendium on occupational therapy and physiotherapy interventions across the life stages in cerebral palsy (Chapter 6). Finally, a promising outcome measure was examined using Rasch modelling. The resultant Revised Pediatric Motor Activity Log (Chapter 7) demonstrated the capacity to yield valid and reliable scores except for children at the extremes of upper limb ability. The randomised trial comparing modified constraint-induced therapy and a block of standard occupational therapy identified no meaningful difference in outcomes between groups. In light of these findings, Chapter 10 contains information for families and care providers regarding implementing modified constraint-induced therapy and standard occupational therapy, including consideration of methodological rigour, benefit, harm, intervention acceptability and integrity, and generalisation of findings. Finally, future directions for research related to modified constraint-induced therapy and other topics explored in this thesis are outlined.

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